Copay
Dispelling An Urban Legend: Frequent Emergency Department Users Have Substantial Burden Of Disease
John Billings & Maria Raven
Health Affairs, December 2013, Pages 2099-2108
Abstract:
Urban legend has often characterized frequent emergency department (ED) patients as mentally ill substance users who are a costly drain on the health care system and who contribute to ED overcrowding because of unnecessary visits for conditions that could be treated more efficiently elsewhere. This study of Medicaid ED users in New York City shows that behavioral health conditions are responsible for a small share of ED visits by frequent users, and that ED use accounts for a small portion of these patients' total Medicaid costs. Frequent ED users have a substantial burden of disease, and they have high rates of primary and specialty care use. They also have linkages to outpatient care that are comparable to those of other ED patients. It is possible to use predictive modeling to identify who will become a repeat ED user and thus to help target interventions. However, policy makers should view reducing frequent ED use as only one element of more-comprehensive intervention strategies for frequent health system users.
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Health Insurance Coverage Predicts Lower Childbearing Among Near-Poor Adolescents
Jacqueline Miller, Deborah Graefe & Gordon De Jong
Journal of Adolescent Health, December 2013, Pages 749-755
Purpose: The impact of health insurance on adolescent childbearing takes on increased salience in the context of the ongoing United States health care debate. Health insurance coverage is important for accessing health care services, including reproductive health services, yet prior research has not examined the association between insurance coverage and childbearing. Consequently, the role of insurance in the prevention of adolescent childbearing has been unclear.
Methods: Using three panels (2001, 2004, and 2008) of the nationally representative Survey of Income and Program Participation data, hierarchical multilevel logistic regression models test the association between pre-pregnancy health insurance coverage and childbearing for a sample of 7,263 unmarried adolescent women (aged 16-19 years), controlling for known correlates of adolescent childbearing. Analyses examine variations in the association based on family income.
Results: The odds of reporting childbearing were almost twice as great for adolescents who were uninsured compared with those who were insured before a pregnancy occurred. Interaction models demonstrate this effect for near-poor adolescents (who are less likely to have health insurance coverage) compared with poor and more advantaged adolescents.
Conclusions: The findings of the current nationally representative study suggest that health insurance coverage is associated with a lower probability of childbearing for near-poor adolescents. Future research should examine potential mechanisms through which insurance coverage influences adolescent childbearing.
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The Effect of Health Insurance on Near-Elderly Health and Mortality
Bernard Black et al.
Northwestern University Working Paper, October 2013
Abstract:
We use the best available longitudinal dataset, the Health and Retirement Survey, and a battery of causal inference methods to provide both central estimates and bounds on the effect of health insurance on health and mortality among the near elderly (initial age 50-61) over an 18-year period. Those uninsured in 1992 consume fewer healthcare services, but are not less healthy and, in our central estimates, do not die sooner than their insured counterparts. We discuss why a zero average effect of uninsurance on mortality and health is plausible, some selection effects that might explain our full results, and methodological concerns with prior studies.
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The Effects of Price Transparency Regulation on Prices in the Healthcare Industry
Hans Bonde Christensen, Eric Floyd & Mark Maffett
University of Chicago Working Paper, October 2013
Abstract:
Policymakers have enacted price transparency regulations in over thirty states during the past decade as an attempt to control rising healthcare costs. This paper provides empirical evidence on the effects of these regulations. Using micro data on actual healthcare purchases, and exploiting both between- and within-state variation to address endogeneity concerns, we find that price transparency regulations reduce the price charged for common, uncomplicated, elective procedures by an average of approximately 7%. Further evidence indicates that the reduction in charge prices is concentrated where competition among providers is most intense and that this reduction is attributable to a decline in the prices charged by the highest priced providers. Among insured patients, reductions in payments are concentrated among the most price sensitive patients, as captured by patients' coinsurance. We also find that insured patients that change providers are more likely to switch to a lower cost provider subsequent to regulation. Overall, our evidence indicates that price transparency regulation leads to a reduction in healthcare prices for patients with incentives to consider costs.
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Competitive bidding in Medicare Advantage: Effect of benchmark changes on plan bids
Zirui Song, Mary Beth Landrum & Michael Chernew
Journal of Health Economics, December 2013, Pages 1301-1312
Abstract:
Bidding has been proposed to replace or complement the administered prices that Medicare pays to hospitals and health plans. In 2006, the Medicare Advantage program implemented a competitive bidding system to determine plan payments. In perfectly competitive models, plans bid their costs and thus bids are insensitive to the benchmark. Under many other models of competition, bids respond to changes in the benchmark. We conceptualize the bidding system and use an instrumental variable approach to study the effect of benchmark changes on bids. We use 2006-2010 plan payment data from the Centers for Medicare and Medicaid Services, published county benchmarks, actual realized fee-for-service costs, and Medicare Advantage enrollment. We find that a $1 increase in the benchmark leads to about a $0.53 increase in bids, suggesting that plans in the Medicare Advantage market have meaningful market power.
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Abby Alpert et al.
Health Affairs, December 2013, Pages 2142-2148
Abstract:
Some Medicare beneficiaries who place 911 calls to request an ambulance might safely be cared for in settings other than the emergency department (ED) at lower cost. Using 2005-09 Medicare claims data and a validated algorithm, we estimated that 12.9-16.2 percent of Medicare-covered 911 emergency medical services (EMS) transports involved conditions that were probably nonemergent or primary care treatable. Among beneficiaries not admitted to the hospital, about 34.5 percent had a low-acuity diagnosis that might have been managed outside the ED. Annual Medicare EMS and ED payments for these patients were approximately $1 billion per year. If Medicare had the flexibility to reimburse EMS for managing selected 911 calls in ways other than transport to an ED, we estimate that the federal government could save $283-$560 million or more per year, while improving the continuity of patient care. If private insurance companies followed suit, overall societal savings could be twice as large.
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Health Information Exchange, System Size and Information Silos
Amalia Miller & Catherine Tucker
Journal of Health Economics, January 2014, Pages 28-42
Abstract:
There are many technology platforms that bring benefits only when users share data. In healthcare, this is a key policy issue, because of the potential cost savings and quality improvements from 'big data' in the form of sharing electronic patient data across medical providers. Indeed, one criterion used for federal subsidies for healthcare information technology is whether the software has the capability to share data. We find empirically that larger hospital systems are more likely to exchange electronic patient information internally, but are less likely to exchange patient information externally with other hospitals. This pattern is driven by instances where there may be a commercial cost to sharing data with other hospitals. Our results suggest that the common strategy of using 'marquee' large users to kick-start a platform technology has an important drawback of potentially creating information silos. This suggests that federal subsidies for health data technologies based on 'meaningful use' criteria, that are based simply on the capability to share data rather than actual sharing of data, may be misplaced.
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Sarah Lyon et al.
Critical Care Medicine, forthcoming
Objective: To use the natural experiment of health insurance reform in Massachusetts to study the impact of increased insurance coverage on ICU utilization and mortality.
Setting: Massachusetts and four states (New York, Washington, Nebraska, and North Carolina) that did not enact reform.
Patients: All nonpregnant nonelderly adults (age 18-64 yr) admitted to nonfederal acute care hospitals in one of the five states of interest were eligible, excluding patients who were not residents of a respective state at the time of admission.
Measurements: We used a difference-in-differences approach to compare trends in ICU admissions and outcomes of in-hospital mortality and discharge destination for ICU patients.
Main Result: Healthcare reform in Massachusetts was associated with a decrease in ICU patients without insurance from 9.3% to 5.1%. There were no significant changes in adjusted ICU admission rates, mortality, or discharge destination. In a sensitivity analysis excluding a state that enacted Medicaid reform prior to the study period, our difference-in-differences analysis demonstrated a significant increase in mortality of 0.38% per year (95% CI, 0.12-0.64%) in Massachusetts, attributable to a greater per-year decrease in mortality postreform in comparison states (-0.37%; 95% CI, -0.52% to -0.21%) compared with Massachusetts (0.01%; 95% CI, -0.20% to 0.11%).
Conclusion: Massachusetts healthcare reform increased the number of ICU patients with insurance but was not associated with significant changes in ICU use or discharge destination among ICU patients. Reform was also not associated with changed in-hospital mortality for ICU patients; however, this association was dependent on the comparison states chosen in the analysis.
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Physicians' Perceptions of Autonomy across Practice Types: Is Autonomy in Solo Practice a Myth?
Katherine Lin
Social Science & Medicine, January 2014, Pages 21-29
Abstract:
Physicians in the United States are now less likely to practice in smaller, more traditional, solo practices, and more likely to practice in larger group practices. Though older theory predicts conflict between bureaucracy and professional autonomy, studies have shown that professions in general, and physicians in particular, have adapted to organizational constraints. However, much work remains in clarifying the nature of this relationship and how exactly physicians have adapted to various organizational settings. To this end, the present study examines physicians' autonomy experiences in different decision types between organization sizes. Specifically, I ask: In what kinds of decisions do doctors perceive autonomous control? How does this vary by organizational size? Using stacked "spell" data constructed from the Community Tracking Study (CTS) Physician Survey (1996-2005) (n=16,519) I examine how physicians' perceptions of autonomy vary between solo/two physician practices, small group practices with three to ten physicians, and large practices with ten or more physicians, in two kinds of decisions: logistic-based and knowledge-based decisions. Capitalizing on the longitudinal nature of the data I estimate how changes in practice size are associated with perceptions of autonomy, accounting for previous reports of autonomy. I also test whether managed care involvement, practice ownership, and salaried employment help explain part of this relationship. I find that while physicians practicing in larger group practices reported lower levels of autonomy in logistic-based decisions, physicians in solo/two physician practices reported lower levels of autonomy in knowledge-based decisions. Managed care involvement and ownership explain some, but not all, of the associations. These findings suggest that professional adaptation to various organizational settings can lead to varying levels of perceived autonomy across different kinds of decisions.
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Pharmaceutical advertising and Medicare Part D
Darius Lakdawalla, Neeraj Sood & Qian Gu
Journal of Health Economics, December 2013, Pages 1356-1367
Abstract:
We explore how and to what extent prescription drug insurance expansions affect incentives for pharmaceutical advertising. When insurance expansions make markets more profitable, firms respond by boosting advertising. Theory suggests this effect will be magnified in the least competitive drug classes, where firms internalize a larger share of the benefits from advertising. Empirically, we find that the implementation of Part D coincides with a 14-19% increase in total advertising expenditures. This effect is indeed concentrated in the least competitive drug classes. The additional advertising raised utilization among non-elderly patients outside the Part D program by about 3.6%. This is roughly half of the direct utilization effect of Part D on elderly beneficiaries. The results suggest the presence of considerable spillover effects from publicly subsidized prescription drug insurance on the utilization and welfare of consumers outside the program.
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The Impact of Insurance Status on the Outcomes after Aneurysmal Subarachnoid Hemorrhage
Pui Man Rosalind Lai et al.
PLoS ONE, October 2013
Abstract:
Investigation into the association of insurance status with the outcomes of patients undergoing neurosurgical intervention has been limited: this is the first nationwide study to analyze the impact of primary payer on the outcomes of patients with aneurysmal subarachnoid hemorrhage who underwent endovascular coiling or microsurgical clipping. The Nationwide Inpatient Sample (2001-2010) was utilized to identify patients; those with both an ICD-9 diagnosis codes for subarachnoid hemorrhage and a procedure code for aneurysm repair (either via an endovascular or surgical approach) were included. Hierarchical multivariate regression analyses were utilized to evaluate the impact of primary payer on in-hospital mortality, hospital discharge disposition, and length of hospital stay with hospital as the random effects variable. Models were adjusted for patient age, sex, race, comorbidities, socioeconomic status, hospital region, location (urban versus rural), and teaching status, procedural volume, year of admission, and the proportion of patients who underwent ventriculostomy. Subsequent models were also adjusted for time to aneurysm repair and time to ventriculostomy; subgroup analyses evaluated for those who underwent endovascular and surgical procedures separately. 15,557 hospitalizations were included. In the initial model, the adjusted odds of in-hospital mortality were higher for Medicare (OR 1.23, p<0.001), Medicaid (OR 1.23, p<0.001), and uninsured patients (OR 1.49, p<0.001) compared to those with private insurance. After also adjusting for timing of intervention, Medicaid and uninsured patients had a reduced odds of non-routine discharge (OR 0.75, p<0.001 and OR 0.42, p<0.001) despite longer hospital stays (by 8.35 days, p<0.001 and 2.45 days, p = 0.005). Variations in outcomes by primary payer-including in-hospital post-procedural mortality-were more pronounced for patients of all insurance types who underwent microsurgical clipping. The observed differences by primary payer are likely multifactorial, attributable to varied socioeconomic factors and the complexities of the American healthcare delivery system.
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Anusua Datta & Dhaval Dave
NBER Working Paper, November 2013
Abstract:
Spending on prescription drugs (Rx) represents one of the fastest growing components of U.S. healthcare spending, and has coincided with an expansion of pharmaceutical promotional spending. Most (83%) of Rx promotion is directed at physicians in the form of visits by pharmaceutical representatives (known as detailing) and drug samples provided to physicians' offices. Such promotion has come under increased public scrutiny, with critics contending that physician-directed promotion may play a role in raising healthcare costs and may unduly affect physicians' prescribing habits towards more expensive, and possibly less cost-effective, drugs. In this study, we bring longitudinal evidence to bear upon the question of how detailing impacts physicians' prescribing behaviors. Specifically, we examine prescriptions and promotion for a particular drug class based on a nationally-representative sample of 150,000 physicians spanning 24 months. The use of longitudinal physician-level data allows us to tackle some of the empirical concerns in the extant literature, virtually all of which has relied on aggregate national data. We estimate fixed-effects specifications that bypass stable unobserved physician-specific heterogeneity and address potential targeting bias. In addition, we also assess differential effects at both the extensive and intensive margins of prescribing behaviors, and differential effects across physician- and market-level characteristics, questions which have not been explored in prior work. The estimates suggest that detailing has a significant and positive effect on the number of new scripts written for the detailed drug, with an elasticity magnitude of 0.06. This effect is substantially smaller than those in the literature based on aggregate information, suggesting that most of the observed relationship between physician-directed promotion and drug sales is driven by selection bias. Qualitatively consistent with the literature, we find that detailing impacts selective brand-specific demand but does not have any substantial effects on class-level demand. Results also indicate that most of the detailing response may operate at the extensive margin; detailing affects the probability of prescribing the drug more than it affects the number of prescriptions conditional on any prescribing. We draw some implications from these estimates with respect to effects on healthcare costs and public health.
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Shanjun Li & Ramanan Laxminarayan
Health Economics, forthcoming
Abstract:
This paper investigates whether patient-level factors, in particular cost considerations, affect the physicians' prescribing decisions. In the context of a natural experiment, we examine the effect of the first US commercial free-antibiotics program on retail antibiotic sales. We find an overall increase in antibiotic prescriptions under the program and substitutions to covered antibiotics from not-covered antibiotics. The shift away from not-covered antibiotics, particularly from those without covered equivalents, indicates a change in the physicians' prescribing decisions. We locate stronger program effects in low-income areas. Our findings, robust to a variety of specifications, are in contrast with previous literature.
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The effect of entry regulation in the health care sector: The case of home health
Daniel Polsky et al.
Journal of Public Economics, forthcoming
Abstract:
The consequences of government regulation in the post-acute care sector are not well understood. We examine the effect of entry regulation on quality of care in home health care by analyzing the universe of hospital discharges during 2006 for publicly insured beneficiaries (about 4.5 million) and subsequent home health admissions to determine whether there is a significant difference in home health utilization, hospital readmission rates, and health care expenditures in states with and without Certificate of Need laws (CON) regulating entry. We identify these effects by looking across regulated and nonregulated states within Hospital Referral Regions, which characterize well-defined health care markets and frequently cross state boundaries. We find that CON states use home health less frequently, but system-wide rehospitalization rates, overall Medicare expenditures, and home health practice patterns are similar. Removing CON for home health would have negligible system-wide effects on health care costs and quality.
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Monica Bharel et al.
American Journal of Public Health, December 2013, Pages S311-S317
Objectives: We studied 6494 Boston Health Care for the Homeless Program (BHCHP) patients to understand the disease burden and health care utilization patterns for a group of insured homeless individuals.
Methods: We studied merged BHCHP data and MassHealth eligibility, claims, and encounter data from 2010. MassHealth claims and encounter data provided a comprehensive history of health care utilization and expenditures, as well as associated diagnoses, in both general medical and behavioral health services sectors and across a broad range of health care settings.
Results: The burden of disease was high, with the majority of patients experiencing mental illness, substance use disorders, and a number of medical diseases. Hospitalization and emergency room use were frequent and total expenditures were 3.8 times the rate of an average Medicaid recipient.
Conclusions: The Affordable Care Act provides a framework for reforming the health care system to improve the coordination of care and outcomes for vulnerable populations. However, improved health care coverage alone may not be enough. Health care must be integrated with other resources to address the complex challenges presented by inadequate housing, hunger, and unsafe environments.
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Who funds their health savings account and why?
Song Chen, Anthony Lo Sasso & Aneesh Nandam
International Journal of Health Care Finance and Economics, December 2013, Pages 219-232
Abstract:
Health savings account (HSA) enrollment has increased markedly in the last several years, but little is known about the factors affecting account funding decisions. We use a unique data set containing from a bank that exclusively services HSA funds linked to health status, benefit design, plan coverage, and enrollee characteristics from a very large national health insurance company to examine the factors associated with HSA contribution. We found that even small employer contributions had an apparently large effect on the decision to open an account: the account-opening rate was 50 % higher when employers contributed to the account. Conditional on opening an HSA, employee contributions were negatively associated with the amount of employer contribution, contributions rose with age, income, education, and health care need.
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Anupam Jena, Eric Sun & John Romley
Circulation, forthcoming
Background: Studies of whether inpatient mortality in U.S. teaching hospitals rises in July as a result of organizational disruption and relative inexperience of new physicians ('July effect') find small and mixed results, perhaps because study populations primarily include low-risk inpatients whose mortality outcomes are unlikely to exhibit a July effect.
Methods and Results: Using the U.S. Nationwide Inpatient sample, we estimated difference-in-difference models of mortality, percutaneous coronary intervention (PCI) rates, and bleeding complication rates, for high and low risk patients with acute myocardial infarction (AMI) admitted to 98 teaching-intensive and 1353 non-teaching-intensive hospitals during May and July 2002 to 2008. Among patients in the top quartile of predicted AMI mortality (high risk), adjusted mortality was lower in May than July in teaching-intensive hospitals (18.8% in May, 22.7% in July, p<0.01), but similar in non-teaching-intensive hospitals (22.5% in May, 22.8% in July, p=0.70). Among patients in the lowest three quartiles of predicted AMI mortality (low risk), adjusted mortality was similar in May and July in both teaching-intensive hospitals (2.1% in May, 1.9% in July, p=0.45) and non-teaching-intensive hospitals (2.7% in May, 2.8% in July, p=0.21). Differences in PCI and bleeding complication rates could not explain the observed July mortality effect among high risk patients.
Conclusions: High risk AMI patients experience similar mortality in teaching- and non-teaching-intensive hospitals in July, but lower mortality in teaching-intensive hospitals in May. Low risk patients experience no such "July effect" in teaching-intensive hospitals.